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Gender Dysphoria and Transsexualism

By George R. Brown, MD, Mountain home VAMC, Johnson City, TN;East Tennessee State University

Gender dysphoria involves a significant discrepancy between a person's anatomic sex and the person's inner sense of self as masculine, feminine, mixed, neutral, or something else (gender identity). This feeling of discrepancy causes the person significant distress or greatly impairs the person's ability to function. Transsexualism is the most extreme form of gender dysphoria.

  • Children focus on activities typically associated with the other sex and have negative feelings about their genitals.

  • Doctors base the diagnosis on symptoms indicating a strong preference to be the other sex.

  • People who feel a strong need to live as the other sex may be helped by counseling, hormone therapy, and sometimes irreversible genital surgery.

People with gender dysphoria believe that they are victims of a biologic accident and that they are cruelly imprisoned in a body incompatible with their inner sense of self as masculine, feminine, or something else (gender identity). For example, some people who are labeled male at birth feel like women trapped in a man's body, and vice versa. Some people feel that they are neither masculine or feminine, that they are somewhere in-between, that they are a combination of the two, or that their identity changes. Genderqueer is a catchall term that refers to some of these variations of gender identity.

In transvestism (cross-dressing), people (almost always men) become sexually aroused by wearing clothing of the opposite sex, but they do not have an inner sense of actually belonging to that sex.


For transsexuals, the incompatibility felt between anatomic sex and gender identify is complete, severe, disturbing, and long-standing. Transsexualism appears to occur in about 1 of 11,900 male and 1 of 30,000 female births.

Most transsexuals are biologic males who identify themselves as females, sometimes early in childhood, and regard their genitals and masculine features with repugnance. However, most children with gender identity problems do not become transsexual adults.

Rarely, transsexuals are people who were born with genitals that are not clearly male or female (ambiguous genitals) or who have a genetic abnormality, such as Turner syndrome or Klinefelter syndrome. However, when children are clearly and consistently considered and reared as either boys or girls, even when genitals are ambiguous, most of them have a clear sense of their gender identity.


Gender dysphoria usually develops by age 2.

Gender dysphoria symptoms in children

Children who have gender dysphoria may do the following:

  • Prefer cross-dressing

  • Insist that they are of the other sex

  • Wish that they would wake up as the other sex

  • Prefer participating in games and activities associated with the other sex

  • Have negative feelings toward their genitals

For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may sit to urinate and wish to be rid of his penis and testes. For boys with gender dysphoria, distress at the physical changes of puberty is often followed by a request for treatment that will make their body more like a woman’s.

However, most children who prefer activities considered to be more appropriate for the other sex (called gender-nonconforming behavior) do not have gender dysphoria.

Gender dysphoria symptoms in adults

Although most transsexuals began having symptoms of gender dysphoria or began feeling different in early childhood, some do not acknowledge these feelings until adulthood.

People, usually men, may be cross-dressers first and not acknowledge their identification with the other sex until later in life. Some of these men marry or join the military as a way to escape or deny their feelings of wanting to be the other sex. Once they accept these feelings, many publicly adopt a satisfying and convincing feminine gender role. Others experience problems, such as anxiety, depression, and suicidal behavior. The stress of not being accepted by society and/or by family may cause or contribute to these problems.


  • A doctor's evaluation

Most children with gender dysphoria are not evaluated until they are 6 to 9 years old.

Doctors diagnose gender dysphoria when people (children or adults) do the following:

  • Feel that their anatomic sex does not match their gender identity and have felt that way for 6 months or longer

  • Feel greatly distressed or cannot function normally because of this feeling

  • Have certain other symptoms, which vary by age group

The other symptoms required for a doctor to diagnose gender dysphoria are slightly different in children and in adolescents and adults.

Children must also have most of the following symptoms:

  • A strong, persistent desire to be or insistence that they are the other gender (or some other gender)

  • A strong preference for dressing in clothing of the opposite gender and, in girls, resistance to wearing typically feminine clothing

  • A strong preference for pretending to be the opposite gender when playing

  • A strong preference for toys, games, and activities typical of the other gender

  • A strong preference for playmates of the other gender

  • A strong rejection of toys, games, and activities typical of the gender that matches their anatomic sex (for example, boys refuse to play with trucks or footballs)

  • A strong dislike of their anatomy

  • A strong desire for the sex characteristics that match their gender identity

Adolescents and adults must also have several of the following symptoms:

  • A strong desire to be rid of their sex characteristics and, for young adolescents, to prevent the development of secondary sex characteristics (those that occur during puberty)

  • A strong desire for the sex characteristics that match their gender identity

  • A strong desire to be the other gender (or some other gender)

  • A strong desire to live or be treated as another gender

  • A strong belief that they feel and react like another gender


  • Psychotherapy

  • Sometimes hormone therapy

  • Sometimes sex-reassignment surgery

Adults who feel that their anatomic sex does not match their gender identity may not require treatment if they do not have psychologic distress or trouble functioning in society.

Transsexuals may seek psychologic help to do one of the following:

  • Assist them in coping with the difficulties of living in a body that they do not feel comfortable with

  • Help them through a gender transition

Treatment is not intended to influence transsexuals to accept their anatomic sex and to change their gender identity.

Many transsexuals appear to be helped most by a combination of psychotherapy, hormone therapy, electrolysis, and sometimes genital (sex-reassignment) surgery (which is irreversible).

Some transsexuals are satisfied with changing their gender role by working, living, and dressing in society as a member of the opposite gender. This approach may include obtaining identification (such as a driver's license) that helps them work and live in society as the opposite gender. They may never seek to alter their anatomy in any way. Many of these people, who are sometimes referred to as transgenderists, do not have symptoms that meet the criteria for a mental health disorder.

Did You Know...

  • Children with gender dysphoria may insist that they are the opposite sex.

Hormone therapy

Other transsexuals, in addition to adopting the behavior, dress, and mannerisms of the opposite sex, receive hormone treatments to change their secondary sex characteristics:

  • In biologic males, use of the female hormone estrogen causes breast growth and other body changes, such as wasting of the genitals (genital atrophy) and the inability to maintain an erection.

  • In biologic females, use of the male hormone testosterone causes such changes as growth of facial hair, deepening of the voice, and changes in body odor and distribution of body fat.

Hormone therapy is all some biologic male transsexuals need to make them feel comfortable as a female.

Sex reassignment surgery

Still other transsexuals request sex reassignment surgery. This surgery is irreversible.

For both sexes, surgery is preceded by

  • Use of the appropriate sex hormone (estrogen in male-to-female transformation and testosterone in female-to-male transformation)

  • Living full-time in the opposite gender role for at least 1 year

For biologic males, surgery involves removal of part of the penis and the testes and creation of an artificial vagina. The part of the penis that is left acts as a clitoris, the remaining part is usually sexually sensitive and makes orgasm possible.

For biologic females, surgery involves removal of the breasts (mastectomy) and sometimes the internal reproductive organs (uterus and ovaries), closure of the vagina, and creation of an artificial penis. Results of female-to-male surgery are less satisfactory than male-to-female surgery in terms of the appearance and function, possibly explaining why fewer female transsexuals request sex-reassignment surgery.

Although transsexuals who have sex reassignment surgery cannot procreate, many are able to have satisfactory sexual relations. The ability to achieve orgasm is often retained after surgery, and some people report feeling comfortable sexually for the first time. However, few transsexuals endure the sex reassignment process for the sole purpose of being able to function sexually as the opposite sex. Confirmation of their inner sense of gender identity is the usual motivation.

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